What is prostate cancer?
Prostate cancer is a type of cancer that begins in the prostate. Signals of prostate cancer may be the same as those of a benign prostatic hyperplasia (BPH, prostate enlargement), inter alia, an attenuated beam during urination, during the night to urinate more frequently and inability to hold the urine hose.
Prostate cancer symptoms
Various symptoms may be due to prostate cancer. Symptoms that may occur include:
- frequent urge feeling
- difficulty coming on stream of urine
- can not manage to maintain a constant stream of urine (outflow speed changes)
- often called a 'residue feeling', where the patient experiences that there is still urine is in the bladder
- urination is painful or burning
- blood in urine or semen
- painful ejaculation (ejaculation)
- thick legs edema (very late symptom)
- malaise
- weight loss
- pain in the lower back, hips or upper part of the thighs
In particular, urinary symptoms, however, can also be the result of a benign enlargement of the prostate gland; having these symptoms do not have to mean that there is prostate cancer. Because prostate grow especially in the peripheral part of the prostate (which areas of the prostate that are not close to the urethra), are only about 4% of cases urinary symptoms input complaint with prostate cancer. Furthermore, there are more complaints occur, depending on how far advanced the cancer is at the time of diagnosis. Tumor is localized, locally advanced or metastatic (medical: metastatic)?
-Localized prostate cancer: The tumor is a view entirely in the prostate. Most patients with localized prostate cancer have no symptoms. However, there may occur a local symptoms such as pain, and lower urinary tract symptoms (LUTS).
-Locally advanced prostate cancer: The tumor has spread beyond the prostate capsule, but there is no evidence of metastases. This extension of prostate cancer, local pain, hematuria (blood in the urine), pain on urination, urinary problems, dribbling, nocturia and pain they cause by obstruction of the urethra and urinary problems in the removal of the kidneys.
-Metastatic (metastatic) prostate cancer: The tumor has spread to other organs or bones. Prostate carcinomas metastasize not often, but it is possible. The edema of the lower limbs may have the effect of (by regional obstruction of the lymphatic vessels), or bone pain from metastases in the skeleton. Also, weight loss can, low blood count and pain in the abdomen or legs (by affecting local nerves or spinal nerves) may occur.
Prostate cancer risk factors
Not much is known yet about the causes of prostate cancer.
- Age; is the primary risk factor for the development of prostate cancer, 80% of cases and 90% of the mortality rate are at the expense of men older than 65 years. At 80-year-olds to a different cause of death appears to be a large part (tens of percent) to have prostate cancer without symptoms.
- Geographical differences; in Western Europe and the United States it is more in proportion to, presumably this is associated with ethnicity, diet and environmental factors.
- Is relatively more common in black Americans.
- Hereditary factors; It is more common in men with a father or son who have prostate cancer. Recently some genes associated with the disorder: the fusion of the prostate-specific gene and ETS family of transcription regulated oncogenes-genes, 11 genes on a small area on chromosome 22 to know 22q 12.3. 8 of the micro satellite DG8S737 and allele on a region on chromosome 8, namely 8q24.
- Xenotropic murine leukemia since 2006 it is suspected that the virus-related virus (XMRV) also plays a role in the development of prostate cancer and in particular in the development of the most aggressive forms.
Prostate cancer diagnosis
Digital rectal examination
In setting the diagnosis uses various investigations involving the physical research and in particular the digital rectal examination usually takes place the first time. By sensing the surface of the prostate, through the index finger into the anus, a specialist can often already feel whether there is a possible malignancy (malignant tumor). To distinguish between possible diagnoses, the following important characteristics:
- symmetrical, smooth and fixed-elastic prostate: normal
- ' normal ' and increases: suspicious for BPH
- ' normal ' pressure and painful: suspicious for prostatitis
- irregular consistency or hard nodule/nodules (lumps): suspected for prostate Carcinoma (predictive value 22-39%).
PSA
Also uses a blood test or a urine test in which the prostate-specific antigen (PSA) is determined. As a rule of thumb, one can assume that a total PSA > 10 ng/ml is highly suspicious for a prostate Carcinoma; at a total 2.5 ng/ml PSA < is this very unlikely.
An elevated PSA level, however, is not specific to prostate cancer:
- When not all forms of prostate cancer, the PSA level increased.
- A raised PSA can indicate for prostate cancer but also for various other issues:
-Benign prostatic hyperplasia
-Prostate Inflammation. In the case of prostatitis are the values often strongly increased, often above 40 ng/ml.
-Drug use, such as ibuprofen
-Infections.
- In addition, the test can not distinguish between fast-growing, potentially lethal prostate cancer and slow-growing, non-lethal prostate cancer.
Therefore, the value of the result must therefore always together with previous measurements, or with other (image forming) examination to be interpreted. PSA screening may play an important role in the follow up of patients treated for prostate cancer, because there is a rapid increase in these men indicates that the cancer has returned.
Based on a review of several studies on PSA screening recommends the US Preventive Services Task Force (USPSTF, an American expert panel that draws up opinions on the basis of the latest scientific literature) routine screening for PSA levels off for all men. PSA screening according to the USPSTF has no benefit for the number of deaths from prostate cancer and the disadvantages are greater than the benefits. After ten years the number of PSA screening test for prostate cancer kill penetrate only few or not back. According to the USPSTF routinely test results in unnecessary and harmful treatments, such as removal of the prostate and radiation. Dr. Richard Ablin, discoverer of PSA PSA screening calls an expensive disaster for public health.
To investigate whether the PSA test really mortality due to prostate cancer occurs is in Rotterdam in 1994 a long-term population study.
Biopsy
When raised suspicion by an increased or, in particular, a fast-rising PSA or abnormal physical examination, one can perform a biopsy. A transrectal ultrasound of the prostate can sometimes reveal prostate cancer, but is particularly useful to take along this road biopsies of the prostate. A pathologist can determine if there are cancer cells in the tissue removed pieces.
Other factors which are of importance in the diagnosis; the presence or absence of prostate cancer in the family, age and ethnicity because they too have a predictive value for prostate cancer risk and aggressiveness of the cancer.
If no (new) biopsy is available, one can estimate the risk of prostate cancer using a specific program:
Prostate cancer prevention
In men, at advanced age who deceased to other causes to be useful is to autopsy in a large percentage (40-50% around the 80th year of life) prostate cancer detection. However grew so slowly that these men that have never known. In this sense comes much for prostate cancer. In young patients the tumor is however significantly more aggressive.
Prostate cancer treatment
In the selection for a treatment of prostate cancer will be taken into account several factors. These are in particular:
- Age of the patient
- Co-morbidities (other conditions or disorders that the patient)
- Factors Tumor say something about the severity (stage / grade of the tumor and the PSA levels of the patient)
- Wishes of the patient
Because multiple factors play a role may not exactly be said what treatment is best for an individual patient. The following treatments are possible, depending on the stage of the tumor:
- In patients with localized prostate cancer may be chosen for asset tracking, removing the prostate gland or irradiating it.
- In patients with locally advanced prostate cancer can be chosen for removal of the prostate gland or irradiating it (possibly in combination with hormonal therapy), or only hormonal therapy. In some cases is active also follow a possibility.
- In patients with metastatic prostate cancer (metastatic) is the treatment palliative in nature and you can choose for hormonal therapy by means of surgical or chemical castration. After an average of (scientific: median) two year the prostate cancer impervious to this kind of treatment. One speaks then of castration resistant prostate cancer.
More information about the different treatments is given below:
- Follow active ("watchful waiting"), actually does not deal with it, is an option for men whose cancer is expected to give the coming years no problems, or for older men. The disease process is actively monitored by periodically a digital rectal examination, PSA testing and biopsy to be carried out. Depending on those results, one can at a later stage, in consultation with the patient still decide to go to treatment about.
-Possible drawbacks: the cancer is not removed, and the risk that the later untreatable; the quality of life can be reduced by anxiety as a result of the idea to live with an untreated cancer.
- Radical prostatectomy, an operation (surgery), wherein the prostate, seminal vesicle and lymph nodes may be removed. In some hospitals that can laparoscopically or through a "Da Vinci Prince Charming" robot. Prostatectomy is a technically difficult operation.
-Possible drawbacks: general risks associated with major surgery as mortality, heart problems, bleeding risk; the cancer is not always removed completely; urinary incontinence; bladder and bowel problems; erectile dysfunction.
- External beam radiation therapy (radiotherapy) multiple doses spread over several weeks.
-Possible benefits: sometimes the cancer is completely eliminated; generally well tolerated; avoidance of the surgical risks.
-Possible drawbacks: the prostate is removed and the cancer may not be made completely harmless; for 5-8 weeks regularly have to come to the hospital; chronic bowel inflammation (proctitis), diarrhea, incontinence, erectile dysfunction, problems with bladder / urination. The surgery should not be performed in men with chronic inflammatory bowel disease (Crohn's disease, ulcerative colitis).
- Internal radiation (brachytherapy is a form of radiation therapy) in which needles with radioactive seeds therein is inserted into the prostate. Under general anesthesia or epidural. Sometimes in combination with external beam radiation therapy or hormone therapy.
-Possible drawbacks: the prostate is removed and the cancer may not be made completely harmless; may not be suitable for a large prostate or more aggressive tumors; urinary retention, incontinence, impotence, cystitis; inflammation of the urethra; chronic bowel inflammation (proctitis).
- Hormonal treatment (hormone therapy). By mouth to ingest or inject medicine that the action of androgens (hormones that cause masculinization: testosterone and related) block or creation of it brakes. Sometimes also referred to by the term "chemical castration". An alternative to this is the surgical removal of the testicles (orchiectomy). The chemical castration is reversible, the surgical not. Applied resources belong to a number of different classes; namely, anti androgens, GnRH agonists GnRH-antagonists (see table 1).
-Possible disadvantages: the prostate is not removed and the cancer may not be fully defused; breast development and female, impotence, diarrhea, osteoporosis (botonkalking), decreased libido, hot flashes, mood disorder and fatigue.
After about 12-18 months, the cancer less sensitive to the hormone treatment. One will then choose an alternative treatment, for example if the PSA increases strongly if there is pain symptoms occur.
- Cryosurgery, destroying the malignant cells by quickly freezing and thawing of the tissue. Through the rectum are quickly freezing and thawing gases on the place. Note: this procedure is (in Netherlands) performed almost only in the context of medical research.
- Chemotherapy is usually used if the cancer has spread. Usually one uses docetaxel (Taxotere). The most common side effects include: reduction in the number of red and white blood cells, hair loss (temporary), nausea, vomiting, mouth ulcers, diarrhea and fatigue. Nowadays there are also evidence that chemotherapy is a useful option for patients where the hormonal treatment no longer effective.
- Bisphosphonates such as clodronaat (Ostac) and zoledronaat (Zometa) can be used to treat bone pain, a notorious complication, which mainly acts as the hormonal treatment no longer effective or there are metastases. Disadvantage is that they should be repeated regularly.
- Internal radiation such as injection with strontium, also treatment for the pain to spread prostate cancer, experience shows that this only once and has more effect than the bisphosphonates.
At a number of men is a combination of these treatment methods needed.